INTELENCE 25 MG TABLET (120 EA ) (NDC: 59676057201)
2015 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
Plan Name |
Monthly Prem. |
De- duct- ible | Does Plan Offer Additional Gap Coverage | Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Plan’s Avg. Retail Drug Price 30-Day |
Tier Nbr. |
Tier Desc. |
30-Day Prfrd. Pharm |
90-Day Mail Order |
Fidelis Medicare $0 Premium (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $841.91 |
Browse Plan Formulary |
Humana Gold Plus H3533-006 (HMO)
|
$0.00 |
$320 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:120 /30Days | $785.33 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (Regional PPO)
|
$0.00 |
$225 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:90 /30Days | $784.70 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Enhanced (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $135.00 | None | $791.41 |
Browse Plan Formulary |
WellCare Value (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$84.00 | $210.00 | Q:120 /30Days | $795.39 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Fidelis Long Term Care Advantage (HMO SNP)
|
$3.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $841.91 |
Browse Plan Formulary |
Humana Gold Plus H3533-013 (HMO)
|
$22.40 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:120 /30Days | $785.33 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$27.10 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | Q:90 /30Days | $784.70 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$28.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$69.00 | $172.50 | Q:120 /30Days | $795.39 |
Browse Plan Formulary |
CDPHP Basic RX (HMO)
|
$29.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $816.32 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO SNP)
|
$33.10 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $841.91 |
Browse Plan Formulary |
|
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Today's Options Advantage Plus 350B (PPO)
|
$34.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $95.00 | None | $816.10 |
Browse Plan Formulary |
Today's Options Premier Plus 350B (PFFS)
|
$34.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $95.00 | None | $816.10 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Classic (HMO)
|
$34.10 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $791.41 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
|
$35.40 |
$320 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $841.91 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H3533-002 (HMO SNP)
|
$36.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$80.00 | $230.00 | Q:120 /30Days | $785.33 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Preferred (HMO SNP)
|
$36.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | None | $791.41 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
WellCare Liberty (HMO SNP)
|
$36.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$86.00 | $215.00 | Q:120 /30Days | $795.39 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $841.91 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$36.90 |
$240 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $841.91 |
Browse Plan Formulary |
Forever Blue Medicare PPO Value (PPO)
|
$36.90 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $787.93 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Maximum (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | $0.00 | None | $791.41 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | $0.00 | None | $791.41 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
CDPHP Value Rx (HMO)
|
$45.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $816.32 |
Browse Plan Formulary |
BasiCare with Part D (PPO)
|
$49.70 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $813.46 |
Browse Plan Formulary |
HumanaChoice H5970-008 (PPO)
|
$55.00 |
$320 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:120 /30Days | $785.33 |
Browse Plan Formulary |
BlueShield Senior Blue 650 Part D (HMO-POS)
|
$63.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $787.93 |
Browse Plan Formulary |
Today's Options Premier Plus 150A (PFFS)
|
$85.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$80.00 | $80.00 | None | $816.10 |
Browse Plan Formulary |
Today's Options Advantage Plus 150A (PPO)
|
$89.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$80.00 | $80.00 | None | $816.10 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
CDPHP Choice Rx (HMO)
|
$95.50 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $816.32 |
Browse Plan Formulary |
GoldValue with Part D (HMO-POS)
|
$103.60 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $813.46 |
Browse Plan Formulary |
BlueShield Senior Blue HMO 652 PartD (HMO)
|
$119.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $787.93 |
Browse Plan Formulary |
Gold PPO with Part D (PPO)
|
$122.60 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$90.00 | $180.00 | None | $813.46 |
Browse Plan Formulary |
CDPHP Core Rx (PPO)
|
$134.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $816.32 |
Browse Plan Formulary |
HumanaChoice H5970-010 (PPO)
|
$157.00 |
$320 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:120 /30Days | $785.33 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Preferred Gold with Part D (HMO-POS)
|
$167.40 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$90.00 | $180.00 | None | $813.46 |
Browse Plan Formulary |
BlueShield Forever Blue Medicare PPO 750 (PPO)
|
$187.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $787.93 |
Browse Plan Formulary |
CDPHP Classic Rx (PPO)
|
$194.50 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $816.32 |
Browse Plan Formulary |
CDPHP Prime Rx (PPO)
|
$276.50 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$80.00 | $200.00 | None | $816.32 |
Browse Plan Formulary |